School of Healthcare Sciences

SCHOOL OF HEALTHCARE SCIENCES
ASSIGNMENT SUBMIT FORM
Student number:
Course: BSc (Hons) in intra & perioperative Practice
Module code and name: HC3076 DISSERTATION
Assignment title: A review of autologous venous harvesting
Coronary Artery Bypass Graft
Declared word count: 9993
A review of autologous venous harvesting Coronary Artery Bypass
Graft
A project submitted in partial fulfillment of the
BSc (Hons) Degree in Intra and Perioperative Practice
yasir almuzaini
C165028
May 2018
Perioperative Practice Programme,
School of Healthcare Studies
Cardiff University
Cardiff CF14 4XN
Perioperative Practice Programme,
Cardiff University
B Sc (Hons) Dissertation
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Acknowledgment
I would like to take this opportunity to express my sincere gratitude and
deep appreciation to my supervisor Paul Hennessey and Fiona Morgan for
their invaluable insight, timely advice, continual guidance, constant
supervision, encouragement and moral support throughout this project.
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Abstract
Coronary artery disease affects the major proportion of the world population. Coronary
artery bypass grafting is a proven technique which provides a long-term survival rate of
patients. The current scope of study evaluates the effectiveness of endoscopic
autologous vein harvesting process as compared to the traditional or open vein
harvesting methods for the purpose of reducing long-term complications. A
methodology to analyze various literature article has been used as the search strategy
to understand the better CABG technique. Review of articles is conducted in
accordance with the PICO procedure to develop research questions. Findings from
secondary sources reveal that EVH has various associated complications that arise
post operations. However, the complications are cases of open harvesting is
considerably lower, therefore selecting EVH as an alternative requires considerable
evaluation.
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Table of Contents
Acknowledgment 3
Abstract...................................................................................................................... 4
Table of Contents....................................................................................................... 5
Introduction................................................................................................................ 6
Methods.................................................................................................................... 14
Search Strategy, Justification for Review...............................................................14
Results with Prisma chart......................................................................................... 16
Discussion................................................................................................................ 19
Limitations................................................................................................................ 33
Recommendations.................................................................................................... 34
Conclusion................................................................................................................ 34
Reference................................................................................................................. 35
Introduction
Coronary artery disease is the most fundamental reason for mortality in the
industrialized nations all over the world (Owens, 2010). It has been estimated that
yearly in excess of one million people in the world suffer from coronary atherosclerosis
disease. Coronary Artery Bypass Grafting (CABG) was first used in the 1960s. From the
middle of 1990s cardiac surgeons made use of endoscopic vein-graft harvesting (EVH)
techniques as opposed to large, incision-based open vein harvesting such that patient
postoperative discomfort and incision-site complications could be improvised. EVH
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applies devices that are certified by the Food and Drug Administration (FDA) on the
basis of considerably applied procedures. There are a wide variety of advantages of
EVH which convinced its widespread adoption(Stone, Maehara, Lansky, de Bruyne,
Cristea, Mintz, Mehran, McPherson, Farhat, Marso & Parise, 2011). Data reveals that
EVH has been used in more than 400,000 coronary artery bypass grafting (CABG)
procedures that were conducted in the U.S. surgical centers.The current scope of study
examines EVH and OVH to evaluate the better one amongst the two. The introduction
covers a brief description along with understanding post-operative complications of the
procedures.
The long saphenous vein (LSV) is the most preferred conduit for coronary artery bypass
grafting (CABG) procedures in spite of increasing usage benefits of multiple arterial
grafting. In open vein harvesting (OVH) LSV is harvested by means of an incision in the
lower limb. A recent procedure to reduce the pain along with the risk of infection in post-
operative cases is depicted by (EVH). The EVH method is used in 70% CABG
procedures in the year 2008 as per data provided by the Society of Thoracic Surgeons’
National Cardiac Database (Hassantash, Bikdeli, Kalantarian, Sadeghian & Afshar,
2008). EVH has been shown to decrease the postoperative risk of leg wound morbidity
with improved cosmetic results, along with enhanced patient satisfaction according to
evidence obtained. EVH has several potential detrimental impacts on vein graft patency
as per clinical outcomes in spite of the several benefits remaining. This review article
comprehensively deals with the technical aspects, outcomes, concerns, and
controversies associated with EVH (Nissen, Nicholls, Wolski, Nesto, Kupfer, Perez,
Jure, De Larochellière, Staniloae, Mavromatis & Saw, 2008).
Patients affected with the coronary artery disease are treated with coronary artery
bypass graft surgery or CABG, as being the most acceptable form of cure. The
condition affecting narrowing of coronary arteries by building up of the plaques in the
arterial walls hinders blood flow thus leading to further cardiac complications. This
reduces oxygen rich blood from entering the heart muscle affecting its functions. The
blocked portion of the arteries is bypassed by replacing the narrowed artery with
another piece of grafts. There is a varied process for vein grafting such as open vein
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grafting, and endoscopic vein harvesting(Lopes, Williams, Mehta, Reyes, Hafley, Allen,
Mack, Peterson, Harrington, Gibson & Califf, 2012). Open vein grafting procedure is a
traditional approach as against EVH. While there remains a debate on the efficacy of
both methods, surgeons make a selection on the basis of post-operative complications
in patients. EVH method has lesser post-operative complications as compared to the
traditional approach. Research conducted in the past reflects that open surgery has
increased rate of complications, with an increased hospital stay, leg pain, and so on. In
the EVH method, there is associated considerable risk of injury that might undermine
the vein graft patency.
The short-term safety along with efficacy of EVH was evident in most studies that were
conducted however the studies did not evaluate the long-term outcomes from
randomized controlled (Menasché, Alfieri, Janssens, McKenna, Reichenspurner,
Trinquart, Vilquin, Marolleau, Seymour, Larghero & Lake, 2008). There have been
conducted a number of an observational study in 2009 that could question the safety of
endoscopic vein-graft harvesting. as being the replacement of open surgery. Studies
depicted that those receiving EVH faced a higher risk from higher 3-year mortality and
1-year angiographic vein graft failure as compared to those who were receiving open
harvesting. This was concluded from a study that examined 3000 CABG patients who
were in the PREVENT IV trial. The importance of venous stasis at the time harvest
creates a pressurized subcutaneous tunnel, along with larger caliber segments for a
harvested vein in EVH procedure, as biological mechanisms in EVH harm extends
greater vessel manipulation (Harskamp, Lopes, Baisden, de Winter & Alexander, 2013).
The confirmation regarding EVH findings from one regional studyof PREVENT IV was
not undertaken.EVH systems with and without carbon dioxide insufflation are used in
disposable systems and reusable in nature. The location of the vein in EVH is identified
by the operator by means of gentle “milking” of the vein after appropriate positioning of
the patient. Ultrasound machine can be applied for localizing the point of care in case
the operator is not able to palpate the vein, portable or osseous landmarks. A 35 cm of
the thigh leg LSV might be harvested from a three cm incision above the medical
condition of the knee. In order to start the harvesting process a 2 to 3 cm on the medial
malleolus part is done, a post which a second incision on the knee for harvesting the
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vein on the groin is done.In case the whole 70 cm length of vein is required, the
changes will need to repeat the processby the same incision towards the other direction
(Khalafi, Bradford & Wilson, 2008). A balloon tip trocar is injected into the incision post
identification of the vein and with the tunnel being inflated with carbon dioxide. On the
anterior surface of the vein examined under videoscopic, the conical dissection cone is
introduced in the direction of the groin. Any clots within the vein are flushed for
removing any clots which might have accumulated. A redivac drain is positioned post
the wound closure and the leg is wrapped along with a compression bandage for a
period of 48 hours and then the tunnel is evacuated from any residual blood(Erbel,
Möhlenkamp, Moebus, Schmermund, Lehmann, Stang, Dragano, Grönemeyer, Seibel, Kälsch
& Bröcker-Preuss, 2010).
Recognizes the complications in the LSV light, Brown and co-workers use optical tomography
(OCT) to study the effects of preheparinization and sealed CO2. Initial Preheparinization prior to
EVH (5000 IU bolus or full dose heparin for activated coagulation time> 300 seconds) in
coagulation fractions and coagulation volume. CO2 insufficient CO2 system is not observed in
the EVH system with an open CO2 insufflation system without preheating.An open CO2 system
can be achieved using the EGF system. There is no difference in low dose and (II) full dose
dosing and (III) in an open CO2 insufflation system without pretreatment (Serruys, Morice,
Kappetein, Colombo, Holmes, Mack, Ståhle, Feldman, van den Brand, Bass & Van
Dyck, 2009).
. Although this study will not be implemented in the future, it is not possible to reduce
the load of a blood clot. The largest saphenous vein (GVS) is the most collected revas-
cularization channel during coronary artery surgery (CABG). Some studies have shown
that the OVH procedure indicates postoperative disease, delayed hospitalization, and
extension. Therefore, a minimally invasive method of reducing surgical damage associ-
ated with OVH has developed over the past decade(Desai, Seifalian & Hamilton, 2011).
There are postoperative infections, illness, impaired mobility, and hospitalization length.
In early studies, there was no significant difference in OVH and EVH procedures within
six months after surgery. However, new studies indicate that EVH can be attributed to
reduced pain. From a histopathological point of view, EVH is very similar to OVH tech -
niques. However, some studies of endothelial cell transmissions do not match the re-
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sults. In recent studies, EVH is associated with increased mortality, myocardial infarc-
tion in first-year surgery after surgery.
Since post-operative theoretical investigations were not systematically performed,
planned CABGenders was decided upon, not on pumps to make their own decisions in
accordance with these procedures (Locker, Schaff, Dearani, Joyce, Park, Burkhart,
Suri, Greason, Stulak, Li & Daly, 2012). OVH and EVH in the coronary bypass method.
In addition to clinical and pathological results, there is a comparison for the EVH and
OVH layers.In recent years, there has been much evidence to focus on ATTH EVH ac-
companied by low morbidity legs, better cosmetic results, and improved patient satisfac-
tion. For all this, despite the benefits of the benefits, there is still some concern about
these potential benefits of this technology on endothelial integrity (McLean, Nazarian,
Gluckman, Schulman, Thiemann, Shapiro, Conte, Thompson, Shafique, McNicholas &
Villines, 2011). However, the results of our study did not show any negative EVH clinical
outcomes and patients had pain in the OVH group. This study was a post-pain pain af-
ter six weeks. The monitoring of the EVH Group has shortened the period significantly
compared to the OVH Group. With the degree of pain (23.1% by volume 6.7%), neural-
gia (24.3% by volume 7.1%) and patient satisfaction (49% V 75%) it can be assumed
that EVH is better in the OVH Group.
One of the other is an infection of complications of venous seizures in the incision. Over
eleven EVH ACE technique associated with SV significantly reduced the rate of infec-
tion site OVH recipients (OR = 0.22, P <0.00001) (Domanski, Mahaffey, Hasselblad,
Brener, Smith, Hillis, Engoren, Alexander, Levy, Chaitman, & Broderick, 2011). Sv An-
other meta-analysis of 35 studies, including the king of the EVH group, the infection rate
(p <0.0001) is maintained. In another study by Raja et al. 2013 where 411 CABG ex -
pects the level of infection at the logging site to be four years. The fact that EVH's tech-
nique virtually eliminated the risk that the technique warns the site of infection, the HVO
(13.1% versus 1.3%, p <0.001). The reason may be the result of a smaller incision and
the safe transfer of this tissue to the surgical procedure. Another important aspect of the
primary outcome is tissue perfusion, which preserves one of the least likely viable tissue
valves(Shahian, O'brien, Filardo, Ferraris, Haan, Rich, Normand, DeLong, Shewan,
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